Journal of Vascular Surgery
Volume 48, Issue 6, Supplement , Pages 37S-44S, December 2008

Laparoscopic aortic surgery: Techniques and results

  • Jérôme Cau, MD

      Affiliations

    • Vascular Surgery Department, University Hospital, Poitiers, France
    • ,
  • Jean-Baptiste Ricco, MD, PhD

      Affiliations

    • Vascular Surgery Department, University Hospital, Poitiers, France
    • Corresponding Author InformationCorrespondence: Jean-Baptiste Ricco, MD, PhD, Vascular Surgery Department, University of Poitiers, Jean Bernard Hospital, Poitiers, France
    • ,
  • Jean-Marc Corpataux, MD

      Affiliations

    • Thoracic and Vascular Surgery Department, University Hospital, Lausanne, Switzerland

Received 2 July 2008; accepted 8 August 2008. published online 23 October 2008.

Article Outline

Objective

This review describes and evaluates the results of laparoscopic aortic surgery.

Methods

We describe the different laparoscopic techniques used to treat aortic disease, including (1) total laparoscopic aortic surgery (TLS), (2) laparoscopy-assisted procedures including hand-assisted laparoscopic surgery (HALS), and (3) robot-assisted laparoscopic surgery, with their current indications. Results of these techniques are analyzed in a systematic review of the clinical series published between 1998 and 2008, each containing >10 patients with complete information concerning operative time, clamping time, conversion rate, length of hospital stay, morbidity, and mortality.

Results

We selected and reviewed 29 studies that included 1073 patients. Heterogeneity of the studies and selection of the patients made comparison with current open or endovascular surgery difficult. Median operative time varied widely in TLS, from 240 to 391 minutes. HALS had the shortest operating time. Median clamping time varied from 60 to 146 minutes in TLS and was shorter in HALS. Median hospital stay varied from 4 to 10 days regardless of the laparoscopic technique. The postoperative mortality rate was 2.1% (95% confidence interval, 1.4-3.0), with no significant difference between patients treated for occlusive disease or for aneurysmal disease. Conversion to open surgery was necessary in 8.1% of patients and was slightly higher with TLS than with laparoscopy-assisted techniques (P = .07).

Conclusions

Analysis of these series shows that laparoscopic aortic surgery can be performed safely provided that patient selection is adjusted to the surgeon's experience and conversion is liberally performed. The future of this technique in comparison with endovascular surgery is still unknown, and it is now time for multicenter randomized trials to demonstrate the potential benefit of this type of surgery.

 

As in other surgical specialties, minimally invasive laparoscopic techniques have evolved progressively in vascular surgery, with a number of reports describing laparoscopic aortic repair for occlusive and aneurysmal disease. Conventional open surgery for occlusive aortic disease still offers the best long-term patency but is associated with significant short-term morbidity. This situation left an opening for endovascular techniques that give good results for TransAtlantic Inter-Society Consensus (TASC) A and B lesions, but are less successful for TASC C and D lesions. Stent grafts are reliable for infrarenal aortic aneurysms, but their use is currently limited by strict anatomic criteria and necessitates a life-long computed tomography scan or duplex ultrasound follow-up, with a significant added cost.

There is therefore a subset of patients who would benefit from less invasive aortic surgery if results were similar to those of open surgery but with a shorter hospital stay, less respiratory complications, a quicker resumption of intestinal transit, less analgesia, and less abdominal wall complications. In this article we describe the laparoscopic techniques currently used for aortic reconstructions, their results, and the conditions required to master these laparoscopic procedures.

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Totally laparoscopic aortic reconstructions 

The techniques that have been described1, 2, 3, 4 to perform totally laparoscopic aortic bypass include the

•retrocolic prerenal transperitoneal approach;

•retrocolic retrorenal transperitoneal approach;

•combined transperitoneal and retroperitoneal approach;

•retroperitoneal approach; and

•direct transperitoneal approach.

Retrocolic prerenal transperitoneal approach 

The transperitoneal procedure described by Coggia et al2, 5 involves exposure of the aorta by a left prerenal colon dissection. The patient is placed in the dorsal decubitus position with an inflatable bolster under the left flank. The left arm remains free, and the right arm is placed on an armrest. The lower extremities are flexed at 30° and positioned parallel to each other. Two supports must be placed on the right side of the thorax and flank to retain the patient when the table is titled to the right (45°) and the bolster is inflated (35°). After the tilting and inflation maneuvers, the patient is in the complete right lateral decubitus position (Fig 1). It is possible to change the patient from the right lateral decubitus position used during exposure of the aorta to the dorsal decubitus position for exposure of the femoral arteries simply by tilting the operating table.

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  • Fig 1. 

    Patient is shown in the right lateral decubitus position for a total laparoscopic retrocolic transperitoneal approach. 1, Operating surgeon; 2, first assistant; 3, second assistant.

The operating surgeon and first assistant stand in front of the patient's abdomen and the second assistant stands opposite the operating surgeon. A 10-mm trocar is placed on the left midaxillary line 3 to 4 cm below the chondrocostal junction. The other five trocars are introduced under visual control after establishing a pneumoperitoneum at a pressure of 12 mm Hg. The two operating ports are placed 6 to 7 cm apart on the left transrectal line parallel to the midline (port 2 is for scissors and needle holder and port 3 is for fenestrated forceps). The two trocars for the first assistant are introduced in the left iliac fossa and on the midline 5 cm from the pubis (port 4 is for the suction catheter and port 5 is for the fenestrated forceps, followed by distal clamp). The last trocar is positioned on the midline 2 cm below the xiphoid process distal (port 1 is for the proximal clamp; Fig 2).

  • View full-size image.
  • Fig 2. 

    A, Position of the ports for retrocolic transperitoneal approach is shown. 1, Retractor/proximal clamp; 2, coagulating scissors/needle holder; 3, blunt grasping forceps; 4, suction system; 5, blunt grasping forceps/distal clamp; 6, 30° angled viewing endoscope. B, Operative view shows operators and the position of ports for a total laparoscopic retrocolic prerenal transperitoneal approach.

The left laterocolic approach involves left colic dissection to achieve prerenal exposure of the aorta. The table is tilted as far as possible to the right (ie, 45°), and the bolster is inflated to enhance the right lateral decubitus position by 30°. The Toldt fascia is incised from the left colic angle to the mesosigmoid to allow complete dissection of the left mesocolon. After identification of the genital vein, prerenal dissection is continued to the left renal vein. With the patient in the right lateral decubitus position, the intestine is retracted on the right side of the abdominal cavity (Fig 3). The mesocolon is then attached to the abdominal wall with transparietal sutures to form an apron providing stable exposure of the aorta.

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  • Fig 3. 

    Aortic exposure through a left retrocolic prerenal approach with the patient in the right lateral decubitus position. The intestinal loops collect on the right side of the abdomen, with the mesocolon forming an apron. This technique provides a stable exposure of the aorta.

The lymphatic tissue surrounding the aorta is dissected free with coagulating scissors, exposing the infrarenal aorta. Use of a 30° or 45° angled viewing endoscope facilitates circumferential aortic visualization, which is necessary for a safe proximal clamping. In case of extensive infrarenal aortic calcifications, the renal vein will need to be mobilized to expose the juxtarenal aorta (Fig 4). Dissection is then extended to the left common iliac artery after control of the inferior mesenteric artery. The right common iliac artery is also dissected for 3 to 5 cm.

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  • Fig 4. 

    A, Complete exposure of the aorta, iliac arteries, and inferior mesenteric artery through a left retrocolic prerenal approach. B, Cross-clamping of the suprarenal aorta for extensive occlusive disease and calcification of the infrarenal aorta (same approach).

For exposure of the femoral arteries, the table is rotated to the left and the bolster deflated. After conventional femoral exposure, the table is again tilted to the right to allow introduction of the bifurcated prosthesis through one of the ports. The right branch of the prosthesis is tunneled in the anatomic position before the proximal anastomosis is made. The extremity of the left branch is ligated and left in the abdomen.

Proximal and distal aortic clamping is performed with laparoscopic clamps (B/Braun/Aesculap, Tuttlingen, Germany; or Storz-France SA, Paris, France) introduced through ports 1 and 5. The anastomosis between the aorta and prosthetic graft is made by two running sutures using 3-0 polypropylene under total laparoscopic guidance. Suturing is performed using an 18-cm-long polypropylene 3-0 suture with one end previously sutured to a pledget to avoid having to tie the first knot (Fig 5). As in open surgery, either an end-to-side or end-to-end anastomosis can be used for treatment of occlusive lesions. In case of an end-to-side aortic anastomosis, Potts scissors are used to perform a longitudinal arteriotomy, and then the anastomosis begins on the heel of the prosthesis with a running suture of the left hemi-circumference using a segment of polypropylene tied to a pledget (Fig 6). The suture of the right hemi-circumference is made in a similar way. The two sutures are tied laparoscopically. In case of an end-to-end anastomosis, the infrarenal aorta is transected with closure of the distal aortic stump using a running polypropylene 3-0 suture.

The left branch of the prosthesis is then tunneled, and femoral anastomoses are performed conventionally while the patient is in the dorsal decubitus position. After removing the clamp, the surgeon decreases the carbon dioxide pressure to 6 mm Hg to check the hemostasis of the aortic anastomosis and to reveal any venous bleeding hidden by the high-pressure pneumoperitoneum. The mesocolon is then repositioned under videoscopic control to separate the graft from the bowel.

This retrocolic prerenal approach has two advantages: It achieves an adequate aortic exposure and provides a large operating space. The small bowel falls to the right part of the abdomen when the patient is placed in a right lateral decubitus position. The left mesocolon acts as a peritoneal apron.6 With this approach, exposure of the right common iliac artery can be difficult and limited to 6 cm. In thin patients or those with a history of left renal or colon surgery, it is better to use a left retrorenal retrocolic approach7 that allows exposure of the aorta up to the celiac region with visceral rotation.

Retrocolic retrorenal transperitoneal approach 

The patient is placed in a right lateral decubitus position with an inflatable pillow placed behind the left flank, and the operating table is at maximal right rotation. The pneumoperitoneum is insufflated. The dissection is conducted from the psoas muscle after incision of the retrorenal fascia. If needed, a right medial visceral rotation is done. The venous renal-azygos-lumbar trunk is sectioned to provide complete exposure of the juxtarenal aorta. Dissection of the infrarenal aorta is conducted from the left iliac artery to the left renal artery. This approach allows a complete exposure of the juxtarenal aorta. The transperitoneal left retrorenal approach is indicated when dissection of the Toldt fascia is impossible in very thin patients or those who have had previous left colon or kidney surgery. It may also be used when suprarenal clamping is needed. According to Coggia et al,7 this approach allows a larger working space than the left videoscopic retroperitoneal approach.

Combined transperitoneal and retroperitoneal procedure 

This combined transperitoneal and retroperitoneal procedure was first described by Dion et al.3, 8, 9, 10 The main feature of the technique is the creation of a peritoneal apron that retains the intestinal loops without reducing the size of the operating cavity. A 10-mm trocar is introduced at the level of the umbilicus to establish the pneumoperitoneum at a pressure of 12 mm Hg. The patient is then placed in the Trendelenburg position at 10° with the table tilted to the right. As initially described by Dion et al, the technique involved two distinct retroperitoneal and transperitoneal maneuvers for dissection of the left parietal peritoneum and attachment to the wall by three transparietal sutures to form a peritoneal apron. The procedure begins with an incision of the left parietal peritoneum about 8 cm anterolateral to the Toldt fascia. Dissection is followed in front of the kidney up to the renal vein. The infrarenal aorta proximal to the inferior mesenteric artery is then dissected. The surgeon moves to the patient's left side to complete the procedure. The apron is then attached to the wall to keep the bowel out of the operating field. As previously described, this technique was subsequently simplified by Coggia et al.2

Retroperitoneal approach 

This laparoscopically assisted technique with a short laparotomy to facilitate the aortic anastomosis was first described by Said et al4 and later developed by Edoga et al.11 The patient is placed in a right lateral decubitus position as for the retrocolic transperitoneal approach. The viewing endoscope is introduced through a 15-mm incision above and medial to the iliac crest using the open retroperitoneoscopic technique with a prior hand dissection of the retroperitoneal space. This dissection should be extended up to the midline to avoid peritoneal tears. Although rarely used, the retroperitoneal procedure is a suitable alternative when the transperitoneal procedure is contraindicated in patients with hostile abdomen and peritoneal adherences or when a complete exposure of the left common iliac artery is needed.12 The main advantage of the retroperitoneal route is to exclude the visceral organs from the operating field, albeit at the expense of a smaller working space with the risk of peritoneal tears.

Direct transperitoneal approach 

Direct laparoscopic transperitoneal exposure of the aorta, as done in open surgery, has been difficult to achieve by laparoscopic techniques due to the lack of a retractor needed for a stable aortic exposure. We developed recently as a prototype, a bowel retractor13 consisting of a net placed in racket-like fashion between two 30-cm-long preshaped flexible steel rods attached to an operating handle. The net is used to gather up and retract the bowel loops (Fig 7). The device is packed in a 10-cm-long × 1-cm-diameter sheath that passes easily through a 10-mm-diameter endoscopic trocar. Inside the sheath, the two blades are in contact on their convex edge. When the operator pushes the handle, the rods exit from the end of the sheath and assume their predefined S shape, thus deploying the net within the abdominal cavity. The retractor holds the bowel loops out of the operating field throughout the procedure. The exact shape of the retractor depends on the size of the net that determines how far the shafts can spread.

  • View full-size image.
  • Fig 7. 

    Total laparoscopic direct transperitoneal exposure as done in open surgery with the use of a self-expandable bowel retractor. The net is used to gather up and to retract the bowel loops.

As in conventional open surgery, direct transperitoneal exposure of the aorta begins by incision of the posterior parietal peritoneum and section of the ligament of Treitz. During this step the retractor is pushed towards the diaphragm to mobilize the duodenum. After division of the preaortic lymphatic tissue and dissection of the left renal vein, the infrarenal aorta is visualized. Use of a 30° viewing telescope greatly facilitates exposure of the infrarenal aorta and its branches, including the inferior mesenteric artery and both common iliac arteries. After completion of the exposure, the proximal aortic clamp is introduced through the working channel and placed below the xiphoid appendix. The distal clamp is introduced through the suprapubic trocar.

Aortic anastomosis is performed as previously described using two running sutures. Femoral anastomoses are done through a conventional approach. After the posterior parietal peritoneum is closed using 3-0 resorbable suture, the retractor is simply removed and the net folds up automatically without further manipulation.

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Laparoscopy-assisted procedures and hand-assisted laparoscopic surgery 

Laparoscopy-assisted aortic procedures may also be performed using hand-assisted laparoscopic surgery (HALS), which enables the surgeon to introduce his or her nondominant hand through a special port while maintaining the pneumoperitoneum. With the patient supine, a midline incision of 7 to 8 cm is performed to allow placement of the port-site device. Through this port, the surgeon's hand is introduced into the abdominal cavity without any carbon dioxide loss.14

The incision site is carefully selected to gain vision of the assumed anastomotic sites. A 10-mm trocar is then placed along the midline below the umbilicus with introduction of a 30° laparoscopic optic and for carbon dioxide insufflations to create a 12-mm Hg pneumoperitoneum. At that point, with the nondominant hand, the surgeon pushes away the bowel loops to the right with tilting of the operating table to the right and in Trendelenburg position. A trocar is then introduced lateral to the border of the left rectus abdominis muscle for dissection of the infrarenal aorta, and another trocar is inserted lateral to the border of the right rectus abdominis muscle.

After laparoscopic dissection of the aorta, the abdominal cavity is deflated and the special port-site device is removed. The bowel is left in place in the right abdomen with the aid of laparoscopic sponges. The incision is kept open with an autostatic retractor. The proximal anastomosis between the aorta and the graft is performed under direct vision with conventional instruments. If a distal anastomosis on the external iliac is planed, an oblique suprainguinal incision is done to expose the artery.

Many studies have proved that HALS is a reliable technique to overcome some technical challenges of totally laparoscopy aortic surgery, mainly the performance of vascular anastomoses. It may have increased not only the feasibility and reproducibility of this type of surgery but also its invasiveness compared with total laparoscopic aortic repair.

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Laparoscopy-assisted procedures and robotic surgery 

The robot may be used in laparoscopy-assisted procedures as well as in total laparoscopic surgery, as previously described.15 However, the complexity of the robotic setup does not warrant its primary use for laparoscopic exposure. Interest in its use becomes more evident when suturing the aortic anastomosis because robotic arms support 5° of freedom. Optimal placements of the robot's arms are usually in ports located on the left axillary line. The use of robots in vascular surgery is thought to result in a better surgical performance by overcoming the long learning curve of vascular suturing. But the system also has some disadvantages, including high cost, complex equipment, risk of interference between the robotic arms, and poor tactile feedback.

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Review of the published series 

Clinical studies eligible for inclusion in this review were those that described laparoscopic aortic surgery with ≥10 patients. In case of duplicate material from the same authors, the larger of the studies or the study with the best-documented data was included for analysis. Only studies with complete data on operative time, clamping time, length of hospital stay, morbidity, mortality, and conversion were selected. A total of 29 eligible articles regrouping 1073 patients remained for analysis, 18 dealing with aortoiliac occlusive disease and 11 with abdominal aortic aneurysm (AAA). The results of laparoscopic aortic surgery in aortoiliac occlusive disease are compiled Table I, Table II, and the results of laparoscopic aortic surgery for AAA in Table III, Table IV.

Table I. Studies reporting total laparoscopic surgery for aortic occlusive disease
First authorYearPatient No.Operative time, minClamping time, minHospital stay, dMortality, No.Conversion, No.
Barbera1199824250(150-450)70(55-120)8(3-25)0/244/24
Dion16200451290±6299±285(4-24)1/515/51
Coggia5200493240(140-450)68(30-120)7(2-57)4/932/93
Olinde17200522267(198-365)90±204(2-7)1/222/22
Lin18200568199±3185±326±21/683/68
Rouers19200530244±1166±55±30/306/30
Remy20200521240(150-420)60(30-120)7(5-30)0/211/21
Dooner21200613390(320-480)35-607(3-14)0/133/13
Cau22200672216±5057±218(5-42)0/722/72
Fourneau14200850328(205-490)69(20-173)5(3-29)0/5011/50

Data are presented as the median ± standard deviation, median (range), and events/total patients.

Table II. Studies reporting laparoscopy assisted, including hand or robot assisted surgery for aortic occlusive disease
First authorYearPatient No.Operative time, minClamping time, minHospital stay, dMortality, No.Conversion, No.
Laparoscopy-assisted
Lacroix23199910350(230-390)NR7(5-13)0/101/10
Alimi24200458238(140-420)54(15-170)8(3-32)2/581/58
Hand-assisted
Kolvenbach25200041149±3536±84±21/413/41
Silva26200218191(160-221)44(38-50)7(5-9)0/181/18
Wijtenburg27200325180(120-290)37(15-60)7(4-15)1/252/25
Debing28200313230(150-270)29(23-72)6(4-42)0/131/13
Fourneau29200546208(155-300)28(15-55)6(3-26)2/461/46
Robot-assisted
Stadler15200627236(180-360)54(40-120)5.30/270/27

NR, Not reported.

Data are presented as the median ± standard deviation, median (range), and events/total patients.

Table III. Studies reporting total laparoscopic aortic surgery for aortic aneurysm
First authorYearPatient No.Operative time, minClamping time, minHospital stay, dMortality, No.Conversion, No.
Edoga11199822391(180-600)146(60-286)6(2-25)2/222/22
Kolvenbach30200437227±3481±3160/376/37
Coggia31200430290(160-420)78(35-230)9(8-37)2/302/30
Coggia32200530255(170-410)80(35-110)9(5-37)1/301/30
Cau22200623251±57101±156(4-12)1/237/23
Coggia33200813260(180-355)77(36-105)10(4-30)0/130/13

Data are presented as the median ± standard deviation, median (range), and events/total patients.

Table IV. Studies reporting laparoscopy assisted, including hand or robot assisted surgery for aortic aneurysm
First authorYearPatient No.Operative time, minClamping time, minHospital stay, dMortality, No.Conversion, No.
Laparoscopy-assisted
Kline34199820246±55NR6±20/202/20
Castronuovo35200060462(90-690)112(43-286)6(1-25)3/603/60
Alimi36200324238(155-360)76(42-160)7(3-21)1/244/24
Hand-assisted
Ferrari372006122257±7076±264.4±1.70/1229/122
Robot-assisted
Kolvenbach30200410243±4196±227±2.40/102/10

NR, Not reported.

Data are presented as the median ± standard deviation, median (range), and events/total patients.

Operative time 

Operative time varied widely among series according to the technique. In totally laparoscopic aortic repair, median time in each series varied from 240 to 390 minutes for occlusive disease and from 250 to 391 minutes for AAA. The HALS procedures had the shortest median operating time, varying from 180 to 230 minutes but with a wide range of values (120 to 345 minutes).

Clamping time 

In totally laparoscopic aortic surgery, the median clamping time of the series varied from 60 to 146 minutes but also with a wide range of values (30 to 286 minutes). Clamping time was shorter in HALS series, with a median time of 29 to 57 minutes (Table I, Table II, Table III, Table IV).

Hospital stay 

The median hospital stay varied from 4 to 10 days in all 29 series regardless of the laparoscopic technique used (Table I, Table II, Table III, Table IV).

Mortality 

The 30-day postoperative mortality rate was 2.1% (95% confidence interval [CI]: 1.4%-3.0%) for the 1073 patients in the 29 series. No significant difference (P = .51) was noted between patients treated for occlusive disease (1.9%; 95% CI, 1.0%-3.3%) and those treated for AAA (2.6%; 95% CI, 1.3-4.7). Postoperative mortality of patients who underwent total laparoscopic procedures was 2.2% (95% CI, 1.2-3.7) and comparable with the 2.1% (95% CI, 1.1%-3.8%) in those who underwent laparoscopy-assisted procedures.

Conversion to open surgery 

Conversions to open surgery occurred in 87 of 1073 patients (8.1%, 95% CI, 6.6%-9.9%; Table I, Table II, Table III, Table IV). There was no significant difference (P = .16) between patients treated for occlusive disease (7.2%; 95% CI, 5.4%-9.4%) and those treated for AAA (9.7%; 95% CI, 7.1%-13.1%). The conversion rate was slightly higher in patients who had totally laparoscopic techniques (9.5%; 95% CI, 7.4%-12.1%) than in patients who had laparoscopy-assisted techniques (6.3%; 95% CI, 4.4%-8.9%). This difference was not significant (P = .07, two-tailed Fisher exact test). Reasons for conversion were multiple, including calcified aorta, bleeding from the lumbar veins or from the aortic anastomosis, and self-imposed operative time or aortic-clamping time limits.18, 23, 30

A significant number of complications occurred during the laparoscopic aortic procedures that were described in these series, including bleeding from lumbar veins that quickly retract behind the spine or ureteral injury due to dissection or tunneling of the graft without visual control with the laparoscopic video camera. Other nonspecific postoperative complications included retroperitoneal hematoma due to extended laparoscopic dissection without drainage of the retroperitoneal space. Acute occlusion of the prosthetic graft was observed in some patients after a lengthy aortic clamp or when a kink occurred in one limb of the graft due to inadequate tunneling done without visual control.

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Discussion 

For many years a growing number of surgical specialties, including gastrointestinal, gynecology, and urology, have incorporated laparoscopic techniques. Vascular surgery has been slow to enter this field. Although several series have demonstrated the feasibility of this technique,1, 2, 3, 4 the adoption of laparoscopic aortic techniques has been slow. One of the reasons is that the best way to start laparoscopic aortic surgery is with an aortofemoral bypass for aortoiliac occlusive disease. However, even for TASC C lesions, traditional bypasses have been replaced by balloon angioplasty and stenting, with a low morbidity and excellent initial technical and clinical results. Therefore, aortoiliac bypasses are now reserved for complex TASC D aortoiliac disease or endovascular failure. This reduces the caseload and increases the technical challenge of the laparoscopic procedures.

The basic concept of laparoscopic aortic surgery is to combine the excellent and durable results observed after conventional open arterial reconstruction with the advantages of a less invasive videoscopic approach. To obtain this goal, two approaches to laparoscopic techniques have been investigated. Initially, laparoscopic procedures were done with the assistance of a minilaparotomy through which aortic anastomoses were performed under direct vision with conventional instruments. More recently, total laparoscopic procedures have been developed to enhance the major advantage of minimally invasive surgery with an easier and faster recovery.

After the pioneer efforts of Dion et al,3 the key to total laparoscopic technique for aortoiliac disease was brought to us by Coggia et al2 with the description of the transperitoneal left retrocolic approach of the abdominal aorta. This technique with a patient in right lateral decubitus provides a large intrusion-free working space that allows dissection of the abdominal aorta and completion of the aortic anastomosis.

As shown in this review and by Nio et al,38 total laparoscopic bypass is now performed for complex aortoiliac occlusive disease or for infrarenal aortic aneurysm with fast recovery, minimal wound discomfort, and apparently less respiratory complications than with conventional open surgery.

Despite these encouraging results, the importance of prior training to obtain the required level of expertise to perform laparoscopic aortic anastomoses, must be emphasized. In addition, because of these technical challenges and the associated steep learning curve, no randomized controlled trials have been done so far to prove the cost/benefit ratio of laparoscopic aortic surgery compared with open or endovascular techniques. We observed in these series an important decrease of pulmonary complications compared with open surgery that could relate to several factors, including avoidance of a large abdominal incision, reduced pain, and fast postoperative physiotherapy. However, contraindications of laparoscopic aortic surgery did exist; namely, unfit patients with severe nontreatable coronary lesions, severe cardiac insufficiency, and renal insufficiency.

Intraoperative data of these series also emphasize the technical challenge of laparoscopic aortic surgery even for well-trained surgeons. Operative times and aortic clamping times were generally longer than usually observed during open aortic surgery. But this additional time was not always associated with operative difficulties and postoperative complications. Among all the series, median blood loss was comparable with figures reported for open aortic surgery. Extreme blood loss was observed in some patients with a severely calcified aorta. However, infrarenal circumferential aortic calcifications are not a contraindication for total laparoscopic aortic repair if suprarenal clamping is possible through a left transperitoneal retrocolic prerenal or retrorenal approach.

The reduction in morbidity with growing experience was also shown in these series with a progressive reduction in the conversion rate. The skills to manage exposure problems or bleeding increase with experience, but despite this evidence, many authors followed a liberal conversion policy with self-imposed operative time limits.

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Conclusions 

Analysis of these series shows that laparoscopic aortic surgery can be performed safely with a low mortality and morbidity, provided that patient selection is adjusted to experience and conversion liberally performed. The future of this technique is still unknown, and it is now time for multicenter randomized trials to demonstrate the potential benefit of laparoscopic aortic surgery.

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Author contributions 


Conception and design: JBR

Analysis and interpretation: JBR

Data collection: JBR, JC

Writing the article: JBR

Critical revision of the article: JBR, JC, JMC

Final approval of the article: JBR, JC, JMC

Statistical analysis: JBR

Obtained funding: Not applicable

Overall responsibility: JBR

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 STATEMENT OF CONFLICT OF INTEREST: Dr Cau has been a paid consultant for BBraun/Aesculap, Tuttlingen, Germany.

PII: S0741-5214(08)01384-0

doi:10.1016/j.jvs.2008.08.033

Journal of Vascular Surgery
Volume 48, Issue 6, Supplement , Pages 37S-44S, December 2008

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